Patients' trust in their physicians and health plans are critical components of the therapeutic relationship, but are also critical to patient decisions. With the advent of managed care, the patient's role as informed decision-maker has become essential. The long term goal of this research is to provide new information about how patients define and experience trust, the disruption of trust, and blame for problems in medical care, by focusing on their experiences with both physicians and health plans. By examining how trust is disrupted, the study will also suggest ways for maintaining patient trust. This project focuses on Medicare beneficiaries, investigating whether they regard their health plans or their physicians differently under managed care from those under the traditional Medicare plan. The study explores how patients over age 65: 1) evaluate a serious problem in their medical care; 2) make judgments about actions by physicians and health plans, deciding whether to maintain trust; and 3) make decisions about whether to give voice to their concerns or switch doctors and/or health plans. The Medicare population has a greater likelihood of medical encounters, but also may experience health care differently from a younger population. The results of this research will be pertinent to public health policy and organization policy within health plans. Two types of information will be identified that will contribute to improving quality: information that consumers need from physicians and plans to make appropriate judgments about their own care; and information that consumers can supply to physicians and plans so they can adjust their actions to improve care. The project uses two complementary methods to understand this complex relationship: in-depth interviews in two states and analysis of a recent national survey on consumer trust in health care. Approximately 100 Medicare beneficiaries are being recruited at two sites in New Mexico and four sites in New Jersey, for one-hour interviews. Volunteers will be screened for experiences in the past year, and to include a diverse sample. The study analyzes data on approximately 400 Medicare beneficiaries from a survey on trust in health care that was fielded in the Summer of 2002.To allow for articulation between these results, measures in both the interview and survey focus on problems, expectations, trust and blame in health care. The interview uses additional measures that will contribute to our understanding of how patients maintain or lose trust.